Clindamycin (Cleocin®)

Based on "Principles and Practice of Infectious Diseases"
written by John E. Bennett, MD

Clindamycin for Bacterial vaginosis

Bacterial vaginosis (BV) is a form of vaginal infection resulting from replacement of the lactobacilli in the vagina with anaerobic bacteria (e.g., Prevotella sp., Mobiluncus sp., G. vaginalis, Ureaplasma, Mycoplasma).

BV is often accompanied with vaginal odor (often described as fishy). About 90% of women notice a mild to moderate discharge. A vaginal pH of 5 or higher strongly suggests BV.

Some medical experts consider bacterial vaginosis to be a sexually transmitted infection.

Both oral and topical clindamycin formulations are effective in treating BV. However oral clindamycin is more effective that topical in preventing the risk of adverse pregnancy outcomes.

Cure rate

Clindamycin cure rate for BV:

• Oral clindamycin: ~94 %8
• Clindamycin vaginal cream: ~86%9

Dosage regimens

Clindamycin dosage regimens for BV:9

• Clindamycin cream 2% one full applicator intravaginally at bedtime for 7 days.
• Oral clindamycin 300 mg twice daily for 7 days.
• Clindamycin ovules 100 mg intravaginally once at bedtime for 3 days.

Alternative treatments for BV

Other medications with proven effectiveness for bacterial vaginosis treatment:

• Metronidazole
• Tinidazole

Clindamycin "pros" and "cons"

Advantages:

• Clindamycin is a useful alternate choice in cases of penicillin and β-lactam allergies.
• Food in the stomach does not interfere with the absorption of clindamycin. The drug is nearly completely absorbed following oral administration.
• Concentrates within phagocytic cells.
• Excellent activity against anaerobic bacteria - highly active against staphylococci and streptococci (with the exception of enterococci)
• High activity against Bacteroides fragilis.
• Penetrates into most skeletal and soft tissues.

Disadvantages:

• Major problem is diarrhea. Up to 30% of patients experience diarrhea, especially when taking the drug orally. This is often due to C. difficile toxins and in a small proportion of cases leads to pseudomembranous colitis. Older age and parenteral administration may increase the risk of diarrhea.
• Pseudomembranous colitis. Clindamycin can cause severe Clostridium difficile associated diarrhea (CDAD), which can be observed over 2 months post treatment. This antibiotic has been considered as highest-risk agent for CDAD1.
• Skin rashes occur in about 10% of patients.
• Clindamycin has mild neuromuscular blocking properties that may intensify the effect of other neuromuscular blocking drugs.
• Virtually no activity against aerobic Gram-negative bacteria.
• Topically applied clindamycin may cause photosensitivity.
• Frequent dosage regimen.
• Possible cross resistance with macrolides.

FDA approved uses

Oral clindamycin:

• Serious respiratory tract infections, including lung abscess, anaerobic lung and pleural space infections
• Serious skin and soft tissue infections
• Septicemia (blood infection)
• Intra-abdominal infections, including peritonitis and intra-abdominal abscess
• Infections of the female pelvis and genital tract, including endometritis, nongonococcal tuboovarian abscess, pelvic cellulitis (parametritis), and infections after surgery
• Streptococcal pharyngitis (see clindamycin for strep throat)

Topical gel:

• Acne vulgaris

Vaginal cream:

• Bacterial vaginosis (nonspecific vaginitis).

Off-label uses

• Otitis media 2
• Bacterial vaginosis (oral) 5
• Toxoplasmosis
• Babesiosis
• Pneumocystis Jirovecii pneumonia 3
• Malaria 4
• Anthrax 6
• Animal bites (in combination with other antibiotics)

Spectrum of antimicrobial activity

Clindamycin has a relatively narrow coverage and is active against7:

Gram-positive aerobes:

• Staphylococcus aureus
• Streptococcus pneumoniae
• Streptococcus pyogenes

Anaerobes:

• Prevotella melaninogenica
• Fusobacterium necrophorum
• Fusobacterium nucleatum
• Peptostreptococcus anaerobius
• Clostridium perfringens
• Bacteroides fragilis

Other bacteria:

• Chlamydia trachomatis

Clindamycin has useful activity against some protozoa, including:

• Toxoplasma gondii
• Plasmodium falciparum
• Babesia spp.

Also, clindamycin is active against the fungus Pneumocystis jirovecii.

Clindamycin has excellent activity against Propionobacterium acnes when applied topically.

Gram-negative bacilli, enterococci, spirochetes, and Rickettsia are NOT susceptible.

Mode of action

Clindamycin is a bacteriostatic antibiotic and prevents bacteria replicating by suppressing the synthesis of proteins.

Clindamycin exerts a prolonged postantibiotic effect7. This antibiotic accumulates in polymorphonuclear leukocytes, alveolar macrophages, and in abscesses.

Time to clear out of the system

The plasma half- life is nearly 2.4 hours.

Historical note

The lincosamides are a small group of antimicrobials with a novel chemical structure. Lincomycins were derived from the Streptomyces species in 1962. The first lincosamide to be discovered was lincomycin. Later, in 1966, clindamycin was discovered as a derivative of lincomycin.

Clindamycin was first approved by the U.S. FDA under the brand name Cleocin® in 1970, and was manufactured by Pharmacia and Upjohn.

Further reading

• Clindamycin vs Penicillin

References

• 1. Gerding DN. Clindamycin, cephalosporins, fluoroquinolones, and Clostridium difficile-associated diarrhea: this is an antimicrobial resistance problem. Clin Infect Dis. 2004 Mar 1;38(5):646-8.
• 2. Ramakrishnan K, Sparks RA, Berryhill WE. Diagnosis and treatment of otitis media. Am Fam Physician. 2007 Dec 1;76(11):1650-8. PubMed
• 3. Nickel P, Schürmann M, Albrecht H, et al. Clindamycin-primaquine for pneumocystis jiroveci pneumonia in renal transplant patients. Infection. 2014 Dec;42(6):981-9. PubMed
• 4. Obonyo CO, Juma EA. Clindamycin plus quinine for treating uncomplicated falciparum malaria: a systematic review and meta-analysis. Malar J. 2012 Jan 4;11:2. PubMed
• 5. Mikamo H, Kawazoe K, Izumi K, Watanabe K, Ueno K, Tamaya T. Comparative study on vaginal or oral treatment of bacterial vaginosis. Chemotherapy. 1997 Jan-Feb;43(1):60-8. PubMed
• 6. Meaney-Delman D, Rasmussen SA, Beigi RH, et al. Prophylaxis and treatment of anthrax in pregnant women. Obstet Gynecol. 2013 Oct;122(4):885-900. PubMed
• 7. Smieja M. Current indications for the use of clindamycin: A critical review. Can J Infect Dis. 1998 Jan;9(1):22-8. PubMed
• 8. Greaves WL, Chungafung J, Morris B, Haile A, Townsend JL. Clindamycin versus metronidazole in the treatment of bacterial vaginosis.Obstet Gynecol. 1988;72:799–802.
• 9. Ferris DG, Litaker MS, Woodward L, Mathis D, Hendrich J. Treatment of bacterial vaginosis: a comparison of oral metronidazole, metronidazole vaginal gel, and clindamycin vaginal cream. J FamPract. 1995;41(5):443–9.
• 10. Bacterial Vaginosis: STD Treatment Guidelines

Published: August 12, 2017
Last updated: April 09, 2018 by eMedExpert staff